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SERVICE REQUEST <br /> Type of Business or Property FAClLRY 1D# SERVICE REQUES # <br /> S�z�U�y,IJL <br /> f OP raR EILUNe PARTY G <br /> FA Narrt <br /> $IrEA00W6S �/�,/ <br /> J 9asrtaw+asr a4ayon J� sas Tm anws <br /> M Zing Addr (It Different Irom�Re dress) <br /> a. <br /> Cin - STATE C ZIP 9 7 SoZ 6 <br /> PHONE#T ase APN# I mu UsEMrueATmN# <br /> Qzll 1097 SW2 3 <br /> PHGNF#2 ui: 803 DrsTRa;T .�. .- LOCATION CODE .: <br /> - � 1 <br /> CONTRACTOR/SPRVICEREOUESTOR <br /> REouESTaR // / 8➢.UHa PAM <br /> Busm s C�+ <br /> PHOtaE3F —O7/ <br /> NG AoDREqFAX$ <br /> / d• <br /> Gorr STATE c ZIP <br /> Q <br /> @ILLING ACKNQWLEDGEMiNT: I.Me undasgned property of business owner,operator or authorized agent of same,adUMWtadge mat 4 sib andlo•project apn <br /> Werk HEALTHSUWrASEHVWONMENTAI HFAr.M aYf54Wl hourly charges axsorfared with iNs prtTjector acuity unit be heed to meormybusiness as Idefe reds glmfu L <br /> I ako carlrfy Ihat i have pmpamd 1171%appl4adon and chat the work to be pwirvv d wig be done m acmn7ame wine ag sm JU4WW 07Mry Onfremrce Cade-c,S*a dWds,STATE <br /> P®ERAL lawn. <br /> APKiCJuRSIGWNRE:z raZJ/��„�- GATE �^ ` C'6 <br /> PRCFERrYl0Wl MOWNER ❑ iUR/RtgNAGEiy ❑ OiHERAunicrr�DAGEvf �J .2v< n. ,r2� <br /> CAARr,.lxrhlKr a6BL1NCPMrY ProWalaaNG'kad0e re shear h rwPdrae Hf* <br /> AUTHORIZATION TO RELEASE INFORMATION;When apPr4able.I,the owner oroperatorof the lrropetd located at the above siW addr=hereby auihoiirs fie release <br /> MY and all ra%Uds-geataChnlrai data Motor environmmiairsb assessment Wbnnadon to the SAN JOAOOw COUNTY PUsuc HEu.TH SERVEU ENV RCNUWAJ.HWALTH DMSICN as sc <br /> sail a evadable antl a[Me same time fT's provided�me army n:4Rsenlafraa <br /> TYPeoFSEAvice REouEST97: , / <br /> J— <br /> C9raMENSS; vl <br /> RECEIVED <br /> SEP 1 8 2000 <br /> SAN <br /> BLIOAQUIN COUNTY <br /> HS OVINES <br /> ENVIRONMENTP.L HEALTH DIVISIOrt <br /> 7NSPECTDR'S SIGHAT'URE Co 8$PGNnttrRE <br /> -APPROVED SY: � . DAA <br /> A=GNEQTo; .. 'L. EawTaeE#: DATE <br /> aaft swoceCompleted (it already completed); <br /> PTT= 27}�j <br /> Fee Amount; 3 r Amount Paid Paymenoale 04 _ I fi CV <br /> • . tiv <br /> Payment Type (` "L Invoice <br /> Z0 35tld d00-l3 H1dIa X689460 EO:Zt 000Z/9T/60 <br />